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Meged-Book T, Frenkel R, Nikonov A, Zeldetz V, Kosto A, Schwarzfuchs D, Freud T, Press Y. Delirium screening in the emergency department: evaluation and intervention. Isr J Health Policy Res 2024; 13:16. [PMID: 38566243 PMCID: PMC10985973 DOI: 10.1186/s13584-024-00603-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/18/2023] [Accepted: 03/09/2024] [Indexed: 04/04/2024] Open
Abstract
BACKGROUND Between 8-17% of older adults, and up to 40% of those arriving from nursing homes, present with delirium upon admission to the Emergency Department (ED). However, this condition often remains undiagnosed by ED medical staff. We investigated the prevalence of delirium among patients aged 65 and older admitted to the ED and assessed the impact of a prospective study aimed at increasing awareness. METHODS The study was structured into four phases: a "pre-intervention period" (T0); an "awareness period" (T1), during which information about delirium and its diagnosis was disseminated to ED staff; a "screening period" (T2), in which dedicated evaluators screened ED patients aged 65 and older; and a "post-intervention period" (T3), following the departure of the evaluators. Delirium screening was conducted using the Brief Confusion Assessment Method (bCAM) questionnaire. RESULTS During the T0 and T1 periods, the rate of delirium diagnosed by ED staff was below 1%. The evaluators identified a delirium rate of 14.9% among the screened older adults during the T2 period, whereas the rate among those assessed by ED staff was between 1.6% and 1.9%. Following the evaluators' departure in the T3 period, the rate of delirium diagnosis decreased to 0.89%. CONCLUSIONS This study underscores that a significant majority of older adult delirium cases remain undetected by ED staff. Despite efforts to increase awareness, the rate of diagnosis did not significantly improve. While the presence of dedicated delirium evaluators slightly increased the diagnosis rate among patients assessed by ED staff, this rate reverted to pre-intervention levels after the evaluators left. These findings emphasize the necessity of implementing mandatory delirium screening during ED triage and throughout the patient's stay.
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Affiliation(s)
- Tehilah Meged-Book
- Faculty of Health Sciences, Ben-Gurion University of the Negev, Beer- Sheva, Israel.
- Department of Internal Medicine, Soroka Medical Center, P.O.B. 151, Beer-Sheva, 84101, Israel.
| | - Reut Frenkel
- Department of Geriatrics, Soroka Medical Center, Beer-Sheva, Israel
| | - Anna Nikonov
- Department of Pharmacy, Soroka University Medical Center, Beer Sheva, Israel
| | - Vladimir Zeldetz
- Faculty of Health Sciences, Ben-Gurion University of the Negev, Beer- Sheva, Israel
- Department of Emergency Medicine, Soroka University Medical Center, Beer-Sheva, Israel
| | - Amit Kosto
- Faculty of Health Sciences, Ben-Gurion University of the Negev, Beer- Sheva, Israel
- Department of Internal Medicine, Soroka Medical Center, P.O.B. 151, Beer-Sheva, 84101, Israel
| | - Dan Schwarzfuchs
- Faculty of Health Sciences, Ben-Gurion University of the Negev, Beer- Sheva, Israel
- Department of Emergency Medicine, Soroka University Medical Center, Beer-Sheva, Israel
| | - Tamar Freud
- Siaal Research Center for Family Medicine and Primary Care, Faculty of Health Sciences, Ben-Gurion University of the Negev, Beer- Sheva, Israel
| | - Yan Press
- Faculty of Health Sciences, Ben-Gurion University of the Negev, Beer- Sheva, Israel
- Department of Geriatrics, Soroka Medical Center, Beer-Sheva, Israel
- Siaal Research Center for Family Medicine and Primary Care, Faculty of Health Sciences, Ben-Gurion University of the Negev, Beer- Sheva, Israel
- Unit for Community Geriatrics, Division of Health in the Community, Ben-Gurion University of the Negev, Beer-Sheva, Israel
- Center for Multidisciplinary Research in Aging, Ben-Gurion University of the Negev, Beer-Sheva, Israel
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2
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Matsuda Y, Tanimukai H, Inoue S, Hirayama T, Kanno Y, Kitaura Y, Inada S, Sugano K, Yoshimura M, Harashima S, Wada S, Hasegawa T, Okamoto Y, Dotani C, Takeuchi M, Kako J, Sadahiro R, Kishi Y, Uchida M, Ogawa A, Inagaki M, Okuyama T. A revision of JPOS/JASCC clinical guidelines for delirium in adult cancer patients: a summary of recommendation statements. Jpn J Clin Oncol 2023; 53:808-822. [PMID: 37190819 DOI: 10.1093/jjco/hyad042] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/02/2023] [Accepted: 04/26/2023] [Indexed: 05/17/2023] Open
Abstract
OBJECTIVE The Japanese Psycho-Oncology Society and the Japanese Association of Supportive Care in Cancer have recently revised the clinical practice guidelines for delirium in adult cancer patients. This article reports the process of developing the revised guidelines and summarizes the recommendations made. METHODS The guidelines were developed in accordance with the Medical Information Network Distribution Service creation procedures. The guideline development group, consisting of multi-disciplinary members, created three new clinical questions: non-pharmacological intervention and antipsychotics for the prevention of delirium and trazodone for the management of delirium. In addition, systematic reviews of nine existing clinical questions have been updated. Two independent reviewers reviewed the proposed articles. The certainty of evidence and the strength of the recommendations were graded using the grading system developed by the Medical Information Network Distribution Service, following the concept of The Grading of Recommendations Assessment, Development, and Evaluation system. The modified Delphi method was used to validate the recommended statements. RESULTS This article provides a compendium of the recommendations along with their rationales, as well as a short summary. CONCLUSIONS These revised guidelines will be useful for the prevention, assessment and management of delirium in adult cancer patients in Japan.
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Affiliation(s)
- Yoshinobu Matsuda
- Department of Psychosomatic Internal Medicine, Kinki-Chuo Chest Medical Center, Sakai, Japan
| | - Hitoshi Tanimukai
- Faculty of Human Health Sciences, Graduate School of Medicine, Kyoto University, Kyoto, Japan
| | - Shinichiro Inoue
- Department of Neuropsychiatry, Okayama University Hospital, Dentistry, and Pharmaceutical Science, Okayama, Japan
| | - Takatoshi Hirayama
- Department of Psycho-Oncology, National Cancer Center Hospital, Tokyo, Japan
| | - Yusuke Kanno
- Department of Home Health and Palliative Care Nursing, Graduate School of Health Care Sciences, Tokyo Medical and Dental University, Tokyo, Japan
| | - Yuichi Kitaura
- Department of Psychiatry, Panasonic Health Insurance Organization Matsushita Memorial Hospital, Moriguchi, Japan
| | - Shuji Inada
- Department of Psychosomatic Medicine, Faculty of Medicine, Kindai University, Osaka-Sayama, Japan
| | - Koji Sugano
- Division of Respiratory Medicine, Juntendo Tokyo Koto Geriatric Medical Center, Tokyo, Japan
| | - Masafumi Yoshimura
- Department of Occupational Therapy, Faculty of Rehabilitation, Kansai Medical University, Hirakata, Japan
| | - Saki Harashima
- Department of Stress Sciences and Psychosomatic Medicine, Graduate School of Medicine, The University of Tokyo, Tokyo, Japan
| | - Saho Wada
- Department of Neuropsychiatry, Nippon Medical School Tamanagayama Hospital, Tokyo, Japan
| | - Takaaki Hasegawa
- Center for Psycho-oncology and Palliative Care, Nagoya City University Hospital, Nagoya, Japan
| | - Yoshiaki Okamoto
- Department of pharmacy, Ashiya Municipal Hospital, Ashiya, Japan
| | - Chikako Dotani
- Department of Pediatrics, The University of Tokyo Hospital, Tokyo, Japan
| | - Mari Takeuchi
- Department of Neuropsychiatry, Keio University School of Medicine, Tokyo, Japan
| | - Jun Kako
- College of Nursing Art and Science, University of Hyogo, Akashi, Japan
| | - Ryoichi Sadahiro
- Department of Psycho-Oncology, National Cancer Center Hospital, Tokyo, Japan
| | - Yasuhiro Kishi
- Department of Psychiatry, Nippon Medical School Musashikosugi Hospital, Kawasaki, Japan
| | - Megumi Uchida
- Department of Psychiatry and Cognitive-Behavioral Medicine, Nagoya City University Graduate School of Medical Sciences, Nagoya, Japan
| | - Asao Ogawa
- Division of Psycho-Oncology, Exploratory Oncology Research and Clinical Trial Center, National Cancer Center, Kashiwa, Japan
| | - Masatoshi Inagaki
- Department of Psychiatry, Faculty of Medicine, Shimane University, Izumo, Japan
| | - Toru Okuyama
- Department of Psychiatry/Palliative Care Center, Nagoya City University West Medical Center, Nagoya, Japan
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3
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Weldingh NM, Mellingsæter MR, Hegna BW, Benth JS, Einvik G, Juliebø V, Thommessen B, Kirkevold M. Impact of a dementia-friendly program on detection and management of patients with cognitive impairment and delirium in acute-care hospital units: a controlled clinical trial design. BMC Geriatr 2022; 22:266. [PMID: 35361136 PMCID: PMC8974092 DOI: 10.1186/s12877-022-02949-0] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/17/2021] [Accepted: 03/11/2022] [Indexed: 11/10/2022] Open
Abstract
Background Frail older persons with cognitive impairment (CI) are at special risk of experiencing delirium during acute hospitalisation. The purpose of this study was to investigate whether a dementia-friendly hospital program contributes to improved detection and management of patients with CI and risk of delirium at an acute-care hospital in Norway. Furthermore, we aimed to explore whether the program affected the detection of delirium, pharmacological treatment, 30-day re-hospitalisation, 30-day mortality and institutionalisation afterwards. Methods This study was part of a larger quality improvement project aiming at developing and implementing a new program for early screening and management of patients with CI. This study, evaluating the program are designed as a controlled clinical trial with a historical control group. It was conducted at two different medical wards at a large acute-care hospital in Norway from September 2018 to December 2019. A total of 423 acute hospitalised patients 75 years of age or older were included in the study. Delirium screening and cognitive tests were recorded by research staff with the 4 ‘A’s Test (4AT) and the Confusion Assessment Measure (CAM), while demographic and medical information was recorded from the electronic medical records (EMR). Results Implementation of the dementia-friendly hospital program did not show any significant changes in the identification of patients with CI. However, the share of patients screened with 4AT within 24 h increased from 0% to 35.5% (P < .001). The proportion of the patients with CI identified by the clinical staff, who received measures to promote “dementia-friendly” care and reduce the risk for delirium increased by 32.2% (P < .001), compared to the control group. Furthermore, the number of patients with CI who were prescribed antipsychotic, hypnotic or sedative medications was reduced by 24.5% (P < .001). There were no differences in delirium detection, 30-day readmission or 30-day mortality. Conclusions A model for early screening and multifactorial non-pharmacological interventions for patients with CI and delirium may improve management of this patient group, and reduce prescriptions of antipsychotic, hypnotic and sedative medications. The implementation in clinical practice of early screening using quality improvement methodology deserves attention. Trial registration The protocol of this study was retrospectively registered in the ClinicalTrials.gov Protocol Registration and Results System with the registration number: NCT04737733 and date of registration: 03/02/2021.
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Affiliation(s)
- N M Weldingh
- Division of Research and Innovation, Department of Research Support Service, Akershus University Hospital, Lørenskog, Norway.
| | - M R Mellingsæter
- Department of Geriatric Medicine, Division of Medicine, Akershus University Hospital, Lørenskog, Norway
| | - B W Hegna
- Division of Research and Innovation, Department of Research Support Service, Akershus University Hospital, Lørenskog, Norway
| | - J Saltyte Benth
- Institute of Clinical Medicine, University of Oslo, Oslo, Norway.,Health Services Research Unit, Akershus University Hospital, Lørenskog, Norway
| | - G Einvik
- Institute of Clinical Medicine, University of Oslo, Oslo, Norway.,Department of Pulmonary Medicine, Division of Medicine, Akershus University Hospital, Lørenskog, Norway
| | - V Juliebø
- Department of Cardiology, Division of Medicine, Akershus University Hospital, Lørenskog, Norway
| | - B Thommessen
- Department of Neurology, Division of Medicine, Akershus University Hospital, Lørenskog, Norway
| | - M Kirkevold
- Faculty of Health Sciences, Department of Nursing and Health Promotion, Oslo Metropolitan University, Oslo, Norway.,Faculty of Medicine, Department of Nursing Science, University of Oslo, Institute of Health and Society, Oslo, Norway
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Flaherty JH, Rodin MB, Morley JE. Changing Hospital Care For Older Adults: The Case for Geriatric Hospitals in the United States. Gerontol Geriatr Med 2022; 8:23337214221109005. [PMID: 35813982 PMCID: PMC9260589 DOI: 10.1177/23337214221109005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
Abstract
Hospital care of frail older adults is far from optimal. Although some geriatric models of care have been shown to improve outcomes, the effect size is small and models are difficult to fully implement, sustain and replicate. The two root causes for these shortcomings are competing interests (high revenue generating diseases, procedures and surgeries) and current hospital cultures (for example a culture of safety that emphasizes bed alarms and immobility rather than frequent ambulation). Geriatric hospitals would be hospitals completely dedicated to the care of frail older patients, a group which is most vulnerable to the negative consequences of a hospitalization. They would differ from a typical adult hospital because they could implement evidence based principles of successful geriatric models of care on a hospital wide basis, which would make them sustainable and allow for scaling up of proven outcomes. Innovative structural designs, unachievable in a typical adult hospital, would enhance mobility while maintaining safety. Financial viability and stability would be a challenge but should be feasible, likely through affiliation with larger health care systems with other hospitals because of cost savings associated with geriatric models of care (decreased length of stay, increased likelihood of discharge home, without increasing costs).
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Affiliation(s)
- Joseph H Flaherty
- Regional Medical Director of Geriatrics, Envision Physician Services, Dallas, Texas, Division of Geriatrics, University of Texas Southwestern, Dallas, Texas, USA
| | - Miriam B Rodin
- Division of Geriatrics, Department of Internal Medicine, Saint Louis University, St Louis, Missouri
| | - John E Morley
- Division of Geriatrics, Department of Internal Medicine, Saint Louis University, St Louis, Missouri
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5
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O'Rourke G, Parker D, Anderson R, Morgan-Trimmer S, Allan L. Interventions to support recovery following an episode of delirium: A realist synthesis. Aging Ment Health 2021; 25:1769-1785. [PMID: 32734773 DOI: 10.1080/13607863.2020.1793902] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/13/2023]
Abstract
OBJECTIVES Persistent delirium is associated with poor outcomes in older adults but little is known about how to support longer-term recovery from delirium. The aim of this review was to identify and synthesise literature to understand mechanisms of recovery from delirium as a basis for designing an intervention that enables more effective recovery. METHODS A systematic search of literature relevant to the research question was conducted in two phases. Phase one focused on studies evaluating the efficacy of interventions to support recovery from delirium, and stage two used a wider search strategy to identify other relevant literature including similar patient groups and wider methodologies. Synthesis of the literature followed realist principles. RESULTS Phase one identified four relevant studies and stage two identified a further forty-six studies. Three interdependent recovery domains and four recovery facilitators were identified. Recovery domains were 1) support for physical recovery through structured exercise programmes; 2) support for cognitive recovery through reality orientation and cognitive stimulation; 3) support for emotional recovery through talking with skilled helpers. Recovery facilitators were 1) involvement and support of carers; 2) tailoring intervention to individual needs, preferences and abilities; 3) interpersonal connectivity and continuity in relationships and; 4) facilitating positive expressions of self. CONCLUSIONS Multicomponent interventions with elements that address all recovery domains and facilitators may have the most promise. Future research should build on this review and explore patients', carers', and professionals' tacit theories about the persistence of delirium or recovery from delirium in order to inform an effective intervention.
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Affiliation(s)
- Gareth O'Rourke
- College of Medicine and Health, University of Exeter, Exeter, England
| | - Daisy Parker
- College of Medicine and Health, University of Exeter, Exeter, England
| | - Rob Anderson
- College of Medicine and Health, University of Exeter, Exeter, England
| | | | - Louise Allan
- College of Medicine and Health, University of Exeter, Exeter, England
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6
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Ukwuoma Ekeozor C, Jeyaruban D, Lasserson D. Where should patients with or at risk of delirium be treated in an acute care system? Comparing the rates of delirium in patients receiving usual care vs alternative care: A systematic review and meta-analysis. Int J Clin Pract 2021; 75:e13859. [PMID: 33236458 DOI: 10.1111/ijcp.13859] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/09/2020] [Revised: 11/10/2020] [Accepted: 11/22/2020] [Indexed: 01/21/2023] Open
Abstract
BACKGROUND Delirium is an acute condition that occurs in hospitalised patients and leads to poor patient outcomes that can last long term. Therefore, the importance of prevention is undeniable and adopting new models of care for at-risk patients should be prioritised. OBJECTIVES This systematic review and meta-analysis will assess the effectiveness of different interventions designed to prevent or manage delirium in acutely unwell hospitalised patients. METHODS MEDLINE, EMBASE, PsycINFO, OpenGrey, Web of Science and reference lists of journals were searched. Eligible studies reported on incidence or duration of delirium, used a validated delirium diagnostic tool and compared an intervention to either a control or another intervention group. Meta-analyses were conducted, and GRADEpro software was used to assess the certainty of evidence. This review is registered on PROSPERO. RESULTS A total of 59 studies were included and 33 were eligible for meta-analysis. Delirium incidence was most significantly reduced by non-pharmacological multicomponent interventions compared with usual care, with pooled risk ratios of 0.57 (95% CI: 0.44 to 0.73, 10 randomised controlled trials) and 0.47 (95% CI: 0.35 to 0.64, six observational studies). Single-component interventions did not significantly reduce delirium incidence compared with usual care in seven randomised trials (risk ratio = 0.92, 95% CI: 0.81 to 1.04). The most effective single-component intervention in reducing delirium incidence was a hospital-at-home intervention (risk ratio = 0.29, 95% CI: 0.09 to 0.87). CONCLUSIONS Non-pharmacological multicomponent interventions are effective in preventing delirium; however, the same cannot be said for other interventions because of uncertain results. There is some evidence that providing multicomponent interventions in patients' homes is more effective than in a hospital setting. Therefore, researching the benefits of hospital-at-home interventions in delirium prevention is recommended.
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Affiliation(s)
| | - Darshana Jeyaruban
- College of Medical and Dental Sciences, University of Birmingham, Birmingham, UK
| | - Daniel Lasserson
- Health Sciences Division, University of Warwick, Coventry, UK
- Department of Geratology, Oxford University Hospitals NHS Foundation Trust, John Radcliffe Hospital, Oxford, UK
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7
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Dasgupta M, Beker L, Schlegel K, Hillier LM, Joworski L, Crunican K, Coulter C. A Non-Pharmacologic Approach to Manage Behaviours in Confused Medically Ill Older Adults in Acute Care. Can Geriatr J 2021; 24:125-137. [PMID: 34079606 PMCID: PMC8137457 DOI: 10.5770/cgj.24.469] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Abstract
Background Non-pharmacological interventions are recommended to manage challenging behaviours among cognitively impaired older adults, however few studies have enrolled patients in acute care. This study aimed to determine the feasibility of implementing non-pharmacological interventions to manage behaviours in hospitalized older adults. Method A self-identity approach was used to identify potentially engaging activities for 13 older medically ill adults admitted to acute hospital; these activities were trialed for a two-week period. Data were collected on frequency of intervention administration and assistance required, as well as frequency of behaviours and neuroleptic use in the seven days prior to and following the trial of activities. Results Per participant, 5–11 interventions were prescribed. Most frequently interventions were tried two or more times (46%); 9% were not tried at all. Staff or family assistance was not required for 27% of activities. The mean number of documented behaviours across participants was 4.8 ± 2.3 in the pre-intervention period and 2.1 ± 1.9 in the post-intervention period. Overall the interventions were feasible and did not result in increasing neuroleptic use Conclusion Non-pharmacologic interventions may be feasible to implement in acute care. More research in this area is justified.
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Affiliation(s)
- Monidipa Dasgupta
- Division of Geriatric Medicine, Shulich School of Medicine, Western University, London, ON.,Lawson Health Research Institute, London, ON
| | | | - Kim Schlegel
- London Health Sciences Centre, London, ON.,Fanshawe College, London, ON
| | - Loretta M Hillier
- GERAS Centre for Aging Research, Hamilton Health Sciences, Hamilton, ON
| | | | | | - Corrine Coulter
- Department of Family Medicine, Shulich School of Medicine, Western University, London, ON
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8
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Carrarini C, Russo M, Dono F, Barbone F, Rispoli MG, Ferri L, Di Pietro M, Digiovanni A, Ajdinaj P, Speranza R, Granzotto A, Frazzini V, Thomas A, Pilotto A, Padovani A, Onofrj M, Sensi SL, Bonanni L. Agitation and Dementia: Prevention and Treatment Strategies in Acute and Chronic Conditions. Front Neurol 2021; 12:644317. [PMID: 33935943 PMCID: PMC8085397 DOI: 10.3389/fneur.2021.644317] [Citation(s) in RCA: 43] [Impact Index Per Article: 14.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/20/2020] [Accepted: 03/12/2021] [Indexed: 01/11/2023] Open
Abstract
Agitation is a behavioral syndrome characterized by increased, often undirected, motor activity, restlessness, aggressiveness, and emotional distress. According to several observations, agitation prevalence ranges from 30 to 50% in Alzheimer's disease, 30% in dementia with Lewy bodies, 40% in frontotemporal dementia, and 40% in vascular dementia (VaD). With an overall prevalence of about 30%, agitation is the third most common neuropsychiatric symptoms (NPS) in dementia, after apathy and depression, and it is even more frequent (80%) in residents of nursing homes. The pathophysiological mechanism underlying agitation is represented by a frontal lobe dysfunction, mostly involving the anterior cingulate cortex (ACC) and the orbitofrontal cortex (OFC), respectively, meaningful in selecting the salient stimuli and subsequent decision-making and behavioral reactions. Furthermore, increased sensitivity to noradrenergic signaling has been observed, possibly due to a frontal lobe up-regulation of adrenergic receptors, as a reaction to the depletion of noradrenergic neurons within the locus coeruleus (LC). Indeed, LC neurons mainly project toward the OFC and ACC. These observations may explain the abnormal reactivity to weak stimuli and the global arousal found in many patients who have dementia. Furthermore, agitation can be precipitated by several factors, e.g., the sunset or low lighted environments as in the sundown syndrome, hospitalization, the admission to nursing residencies, or changes in pharmacological regimens. In recent days, the global pandemic has increased agitation incidence among dementia patients and generated higher distress levels in patients and caregivers. Hence, given the increasing presence of this condition and its related burden on society and the health system, the present point of view aims at providing an extensive guide to facilitate the identification, prevention, and management of acute and chronic agitation in dementia patients.
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Affiliation(s)
- Claudia Carrarini
- Department of Neuroscience, Imaging and Clinical Sciences, University G. d'Annunzio of Chieti-Pescara, Chieti, Italy
| | - Mirella Russo
- Department of Neuroscience, Imaging and Clinical Sciences, University G. d'Annunzio of Chieti-Pescara, Chieti, Italy
| | - Fedele Dono
- Department of Neuroscience, Imaging and Clinical Sciences, University G. d'Annunzio of Chieti-Pescara, Chieti, Italy
| | - Filomena Barbone
- Department of Neuroscience, Imaging and Clinical Sciences, University G. d'Annunzio of Chieti-Pescara, Chieti, Italy
| | - Marianna G Rispoli
- Department of Neuroscience, Imaging and Clinical Sciences, University G. d'Annunzio of Chieti-Pescara, Chieti, Italy
| | - Laura Ferri
- Department of Neuroscience, Imaging and Clinical Sciences, University G. d'Annunzio of Chieti-Pescara, Chieti, Italy
| | - Martina Di Pietro
- Department of Neuroscience, Imaging and Clinical Sciences, University G. d'Annunzio of Chieti-Pescara, Chieti, Italy
| | - Anna Digiovanni
- Department of Neuroscience, Imaging and Clinical Sciences, University G. d'Annunzio of Chieti-Pescara, Chieti, Italy
| | - Paola Ajdinaj
- Department of Neuroscience, Imaging and Clinical Sciences, University G. d'Annunzio of Chieti-Pescara, Chieti, Italy
| | - Rino Speranza
- Department of Neuroscience, Imaging and Clinical Sciences, University G. d'Annunzio of Chieti-Pescara, Chieti, Italy
| | - Alberto Granzotto
- Department of Neuroscience, Imaging and Clinical Sciences, University G. d'Annunzio of Chieti-Pescara, Chieti, Italy.,Behavioral Neurology and Molecular Neurology Units, Center for Advanced Studies and Technology-CAST, University G. d'Annunzio of Chieti-Pescara, Chieti, Italy.,Institute for Mind Impairments and Neurological Disorders-iMIND, University of California, Irvine, Irvine, CA, United States
| | - Valerio Frazzini
- Behavioral Neurology and Molecular Neurology Units, Center for Advanced Studies and Technology-CAST, University G. d'Annunzio of Chieti-Pescara, Chieti, Italy.,Institut du Cerveau et de la Moelle épinière, ICM, INSERM UMRS 1127, CNRS UMR 7225, Pitié Salpêtrière Hospital, Paris, France.,AP-HP, GH Pitie-Salpêtrière-Charles Foix, Epilepsy Unit and Neurophysiology Department, Paris, France
| | - Astrid Thomas
- Department of Neuroscience, Imaging and Clinical Sciences, University G. d'Annunzio of Chieti-Pescara, Chieti, Italy
| | - Andrea Pilotto
- Neurology Unit, Department of Clinical and Experimental Sciences, University of Brescia, Brescia, Italy.,Parkinson's Disease Rehabilitation Centre, FERB ONLUS-S. Isidoro Hospital, Trescore Balneario, Italy
| | - Alessandro Padovani
- Neurology Unit, Department of Clinical and Experimental Sciences, University of Brescia, Brescia, Italy
| | - Marco Onofrj
- Department of Neuroscience, Imaging and Clinical Sciences, University G. d'Annunzio of Chieti-Pescara, Chieti, Italy.,Behavioral Neurology and Molecular Neurology Units, Center for Advanced Studies and Technology-CAST, University G. d'Annunzio of Chieti-Pescara, Chieti, Italy
| | - Stefano L Sensi
- Department of Neuroscience, Imaging and Clinical Sciences, University G. d'Annunzio of Chieti-Pescara, Chieti, Italy.,Behavioral Neurology and Molecular Neurology Units, Center for Advanced Studies and Technology-CAST, University G. d'Annunzio of Chieti-Pescara, Chieti, Italy
| | - Laura Bonanni
- Department of Neuroscience, Imaging and Clinical Sciences, University G. d'Annunzio of Chieti-Pescara, Chieti, Italy.,Behavioral Neurology and Molecular Neurology Units, Center for Advanced Studies and Technology-CAST, University G. d'Annunzio of Chieti-Pescara, Chieti, Italy
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9
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Friedman JI, Li L, Kirpalani S, Zhong X, Freeman R, Cheng YT, Alfonso FL, McAlpine G, Vakil A, Macon B, Francaviglia P, Cassara M, LoPachin V, Reina K, Davis K, Reich D, Craven CK, Mazumdar M, Siu AL. A Multi-Phase Quality Improvement Initiative for the Treatment of Active Delirium in Older Persons. J Am Geriatr Soc 2020; 69:216-224. [PMID: 33150615 DOI: 10.1111/jgs.16897] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/07/2020] [Revised: 09/22/2020] [Accepted: 09/26/2020] [Indexed: 12/01/2022]
Abstract
BACKGROUND/OBJECTIVES The Hospital Elder Life Program emerged 20 years ago as the reference model for delirium prevention in hospitalized older patients. However, implementation has been achieved at only 200 hospitals worldwide over the last 20 years. Among the barriers to implementation for some institutions is an unwillingness of hospital administration to assume the costs associated with implementing programs that service all hospitalized older patients at risk for delirium. Facing such a situation, we implemented a unique and self-evolving model of care of older hospitalized patients who had already developed delirium. DESIGN Hypothesis testing was carried out using a pretest-posttest design on program administrative data. SETTING Mount Sinai Hospital, New York, NY, a tertiary-care teaching facility. PARTICIPANTS A total of 9,214 consecutively admitted older patients to non-intensive care (ICU) inpatient units over a 5.5-year period, regardless of the suspected presence of delirium or risk status for developing delirium. INTERVENTION A delirium intervention program targeting patients in whom delirium has already developed, with a modified delirium team supported by extensive workflow automation with custom tools in our electronic medical records system. MEASUREMENTS Length of stay (LOS) for delirious and non-delirious patients on units where this program was piloted. Benzodiazepine, opiate, and antipsychotic use on the same units. RESULTS There was a significant drop in LOS by 1.98 days (95% confidence interval = .24-3.71), a decrease in the average morphine dose equivalents administered from .38 mg to .21 mg per patient hospital day, diazepam dose equivalents from .22 mg to .15 mg per patient hospital day, and quetiapine administered from .17 mg to .14 mg per patient hospital day for delirious patients on the program pilot units. CONCLUSION Elements of our unique active delirium treatment program may provide some direction to other program developers working on improving the care of older hospitalized delirious patients. However, the supporting evidence presented is limited, and a more rigorous prospective study is needed.
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Affiliation(s)
- Joseph I Friedman
- Department of Psychiatry, Icahn School of Medicine at Mount Sinai, New York, New York.,Department of Neuroscience, Icahn School of Medicine at Mount Sinai, New York, New York
| | - Lihua Li
- Population Health Science and Policy, Icahn School of Medicine at Mount Sinai, New York, New York.,Institute for Health Care Delivery Science, Icahn School of Medicine at Mount Sinai, New York, New York, 10029
| | | | - Xiaobo Zhong
- Population Health Science and Policy, Icahn School of Medicine at Mount Sinai, New York, New York.,Institute for Health Care Delivery Science, Icahn School of Medicine at Mount Sinai, New York, New York, 10029
| | - Robert Freeman
- Clinical Operations, Mount Sinai Hospital, New York, New York
| | - Yim Tan Cheng
- EPIC Clinical Transformation Group, Mount Sinai Health System, New York, New York
| | - Francis L Alfonso
- EPIC Clinical Transformation Group, Mount Sinai Health System, New York, New York
| | - George McAlpine
- EPIC Clinical Transformation Group, Mount Sinai Health System, New York, New York
| | - Aditi Vakil
- EPIC Clinical Transformation Group, Mount Sinai Health System, New York, New York
| | - Bernard Macon
- EPIC Clinical Transformation Group, Mount Sinai Health System, New York, New York
| | - Paul Francaviglia
- EPIC Clinical Transformation Group, Mount Sinai Health System, New York, New York
| | - Margherita Cassara
- EPIC Clinical Transformation Group, Mount Sinai Health System, New York, New York
| | - Vicki LoPachin
- Division of General Internal Medicine, Icahn School of Medicine at Mount Sinai, New York, New York
| | - Katherine Reina
- Department of Nursing, Mount Sinai Hospital, New York, New York
| | - Kenneth Davis
- Department of Psychiatry, Icahn School of Medicine at Mount Sinai, New York, New York.,President's Office, Mount Sinai Health System, New York, New York
| | - David Reich
- Department of Anesthesiology, Icahn School of Medicine at Mount Sinai, New York, New York
| | - Catherine K Craven
- Population Health Science and Policy, Icahn School of Medicine at Mount Sinai, New York, New York
| | - Madhu Mazumdar
- Population Health Science and Policy, Icahn School of Medicine at Mount Sinai, New York, New York.,Institute for Health Care Delivery Science, Icahn School of Medicine at Mount Sinai, New York, New York, 10029
| | - Albert L Siu
- Population Health Science and Policy, Icahn School of Medicine at Mount Sinai, New York, New York.,Geriatrics and Palliative Medicine, Icahn School of Medicine at Mount Sinai, New York, New York.,Department of Medicine, Icahn School of Medicine at Mount Sinai, New York, New York
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10
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Chang HC(R, Neal K, Traynor V, Ho MH, Kankom W. Delirium Among Hospitalized Older Adults in Thailand: An Integrative Review. J Gerontol Nurs 2020; 46:43-52. [DOI: 10.3928/00989134-20200504-01] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/02/2019] [Accepted: 02/03/2020] [Indexed: 12/19/2022]
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11
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Hosie A, Siddiqi N, Featherstone I, Johnson M, Lawlor PG, Bush SH, Amgarth-Duff I, Edwards L, Cheah SL, Phillips J, Agar M. Inclusion, characteristics and outcomes of people requiring palliative care in studies of non-pharmacological interventions for delirium: A systematic review. Palliat Med 2019; 33:878-899. [PMID: 31250725 DOI: 10.1177/0269216319853487] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/25/2022]
Abstract
BACKGROUND Delirium is common, distressing, serious and under-researched in specialist palliative care settings. OBJECTIVES To examine whether people requiring palliative care were included in non-pharmacological delirium intervention studies in inpatient settings, how they were characterised and what their outcomes were. DESIGN Systematic review (PROSPERO 2017 CRD42017062178). DATA SOURCES Systematic search in March 2017 for non-pharmacological delirium intervention studies in adult inpatients. Database search terms were 'delirium', 'hospitalisation', 'inpatient', 'palliative care', 'hospice', 'critical care' and 'geriatrics'. Scottish Intercollegiate Guidelines Network methodological checklists guided risk of bias assessment. RESULTS The 29 included studies were conducted between 1994 and 2015 in diverse settings in 15 countries (9136 participants, mean age = 76.5 years (SD = 8.1), 56% women). Most studies tested multicomponent interventions (n = 26) to prevent delirium (n = 19). Three-quarters of the 29 included studies (n = 22) excluded various groups of people requiring palliative care; however, inclusion criteria, participant diagnoses, illness severity and mortality indicated their presence in almost all studies (n = 26). Of these, 21 studies did not characterise participants requiring palliative care or report their specific outcomes (72%), four reported outcomes for older people with frailty, dementia, cancer and comorbidities, and one was explicitly focused on people receiving palliative care. Study heterogeneity and limitations precluded definitive determination of intervention effectiveness and only allowed interpretations of feasibility for people requiring palliative care. Acceptability outcomes (intervention adverse events and patients' subjective experience) were rarely reported overall. CONCLUSION Non-pharmacological delirium interventions have frequently excluded and under-characterised people requiring palliative care and infrequently reported their outcomes.
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Affiliation(s)
- Annmarie Hosie
- 1 IMPACCT, University of Technology Sydney, Ultimo, NSW, Australia
| | | | | | | | - Peter G Lawlor
- 4 Division of Palliative Care, Department of Medicine, University of Ottawa, Ottawa, ON, Canada.,5 Division of Palliative Care, Bruyère Continuing Care, Élisabeth Bruyère Hospital, Ottawa, ON, Canada.,6 Ottawa Hospital Research Institute, Ottawa, ON, Canada.,7 Bruyère Research Institute, Ottawa, ON, Canada
| | - Shirley H Bush
- 4 Division of Palliative Care, Department of Medicine, University of Ottawa, Ottawa, ON, Canada.,5 Division of Palliative Care, Bruyère Continuing Care, Élisabeth Bruyère Hospital, Ottawa, ON, Canada.,6 Ottawa Hospital Research Institute, Ottawa, ON, Canada.,7 Bruyère Research Institute, Ottawa, ON, Canada
| | | | - Layla Edwards
- 1 IMPACCT, University of Technology Sydney, Ultimo, NSW, Australia
| | | | - Jane Phillips
- 1 IMPACCT, University of Technology Sydney, Ultimo, NSW, Australia
| | - Meera Agar
- 1 IMPACCT, University of Technology Sydney, Ultimo, NSW, Australia
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12
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Effect of dynamic light at the coronary care unit on the length of hospital stay and development of delirium: a retrospective cohort study. JOURNAL OF GERIATRIC CARDIOLOGY : JGC 2018; 15:567-573. [PMID: 30344540 PMCID: PMC6188980 DOI: 10.11909/j.issn.1671-5411.2018.09.006] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 11/21/2022]
Abstract
Background Disturbed circadian rhythm is a potential cause of delirium and is linked to disorganisation of the circadian rhythmicity. Dynamic light (DL) could reset the circadian rhythm by activation of the suprachiasmatic nucleus to prevent delirium. Evidence regarding the effects of light therapy is predominantly focused on psychiatric disorders and circadian rhythm sleep disorders. In this study, we investigated the effect of DL on the total hospital length of stay (LOS) and occurrence of delirium in patients admitted to the Coronary Care Unit (CCU). Methods This was a retrospective cohort study. Patients older than 18 years, who were hospitalized longer than 12 h at the CCU and had a total hospital LOS for at least 24 h, were included. Patients were assigned to a room with DL (n = 369) or regular lighting conditions (n = 379). DL was administered at the CCU by two ceiling-mounted light panels delivering light with a colour temperature between 2700 and 6500 degrees Kelvin. Reported outcome data were: total hospital LOS, delirium incidence, consultation of a geriatrician and the amount of prescripted antipsychotics. Results Between May 2015 and May 2016, data from 748 patients were collected. Baseline characteristics, including risk factors provoking delirium, were equal in both groups. Median total hospital LOS in the DL group was 100.5 (70.8–186.0) and 101.0 (73.0–176.4) h in the control group (P = 0.935). The incidence of delirium in the DL and control group was 5.4% (20/369) and 5.0% (19/379), respectively (P = 0.802). No significant differences between the DL and control group were observed in secondary endpoints. Subgroup analysis based on age and CCU LOS also showed no differences. Conclusion Our study suggests exposure to DL as an early single approach does not result in a reduction of total hospital LOS or reduced incidence of delirium. When delirium was diagnosed, it was associated with poor hospital outcome.
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13
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Yates M, Watts JJ, Bail K, Mohebbi M, MacDermott S, Jebramek JC, Brodaty H. Evaluating the Impact of the Dementia Care in Hospitals Program (DCHP) on Hospital-Acquired Complications: Study Protocol. INTERNATIONAL JOURNAL OF ENVIRONMENTAL RESEARCH AND PUBLIC HEALTH 2018; 15:E1878. [PMID: 30720792 PMCID: PMC6165270 DOI: 10.3390/ijerph15091878] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 07/04/2018] [Revised: 08/24/2018] [Accepted: 08/25/2018] [Indexed: 12/03/2022]
Abstract
Despite the increasing number of older people, many with cognitive impairment (CI), in hospitals, there is yet to be an evaluation of hospital-wide interventions improving the management of those with CI. In hospitalized patients with CI, there are likely to be associations between increased complications that impact on outcomes, length of stay, and costs. This prospective study will evaluate the effectiveness of an established hospital CI support program on patient outcomes, patient quality of life, staff awareness of CI, and carer satisfaction. Using a stepped-wedge, continuous-recruitment method, the pre-intervention patient data will provide the control data for usual hospital care. The intervention, the Dementia Care in Hospitals Program, provides hospital-wide CI awareness and support education, and screening for all patients aged 65+, along with a bedside alert, the Cognitive Impairment Identifier. The primary outcome is a reduction in hospital-acquired complications: urinary tract infections, pressure injuries, pneumonia and delirium. Secondary outcome measures include cost effectiveness, patient quality of life, carer satisfaction, staff awareness of CI, and staff perceived impact of care. This large-sample study across four sites offers an opportunity for research evaluation of health service functioning at a whole-of-hospital level, which is important for sustainable change in hospital practice.
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Affiliation(s)
- Mark Yates
- Ballarat Health Services, Deakin University, Faculty of Health, School of Medicine, Ballarat, VIC 3350, Australia.
- School of Psychiatry, University of New South Wales, Sydney, NSW 2052, Australia.
| | - Jennifer J Watts
- Centre for Population Health Research, Faculty of Health, Deakin University, Burwood, VIC 3125, Australia.
| | - Kasia Bail
- Health Research Institute and Synergy Nursing and Midwifery Research Centre, University of Canberra, Canberra, ACT 2617, Australia.
| | - Mohammadreza Mohebbi
- Biostatistics Unit, Faculty of Health, Deakin University, Geelong, VIC 3220, Australia.
| | - Sean MacDermott
- La Trobe University, School of Rural Health, Mildura, VIC 3520, Australia.
| | | | - Henry Brodaty
- Centre for Healthy Brain Ageing, Dementia Collaborative Research Centre, University of New South Wales, Sydney, NSW 2052, Australia.
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14
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Brown EG, Josephson SA, Anderson N, Reid M, Lee M, Douglas VC. Evaluation of a multicomponent pathway to address inpatient delirium on a neurosciences ward. BMC Health Serv Res 2018; 18:106. [PMID: 29433572 PMCID: PMC5809949 DOI: 10.1186/s12913-018-2906-3] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/24/2017] [Accepted: 01/31/2018] [Indexed: 01/28/2023] Open
Abstract
Background Delirium is a frequent and detrimental complication of inpatient hospitalization. Multicomponent intervention in selected groups has been shown to prevent and treat delirium, though little data exists on the effect of intervention in neurological patients. We studied the efficacy of a multicomponent delirium care pathway implemented on a largely neurology and neurosurgery hospital ward among unselected patients. Methods We incorporated a multicomponent delirium care pathway into the workflow of a university hospital for patients older than 50 years. The pathway involved risk-stratification for development of delirium, delirium screening, and non-pharmacologic behavioral prevention and intervention. We then retrospectively reviewed admissions before and after implementation of the care pathway. Our primary endpoint was incidence of delirium; secondary endpoints included delirium days, length of stay, restraint use, readmission rates, and discharge disposition. Results Seven hundred ninety eight admissions from before the delirium care pathway went into effect and 797 admissions from afterwards were reviewed. Baseline characteristics between groups were similar. Delirium incidence between the two groups did not change (7.0% before vs 7.2% after, p = 0.89). Length of stay among delirious patients significantly decreased after implementation of the delirium care pathway (9.60 before vs 7.06 after, β = − 0.16, adjusted p-value = 0.001). Conclusion Implementation of a delirium care pathway on a neurosciences ward was not associated with changes in the rate of delirium development, though length of stay among delirious patients decreased. In a largely neurologic population, multicomponent intervention to prevent and treat delirium may not change delirium incidence, but may be effective in mitigating delirium complications.
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Affiliation(s)
- Ethan G Brown
- Department of Neurology, University of California, San Francisco, CA, USA.
| | - S Andrew Josephson
- Department of Neurology, University of California, San Francisco, CA, USA
| | - Noriko Anderson
- Department of Neurology, University of California, Irvine, USA
| | - Mary Reid
- Department of Neurology, University of California, San Francisco, CA, USA
| | - Melissa Lee
- Department of Neurology, University of California, San Francisco, CA, USA
| | - Vanja C Douglas
- Department of Neurology, University of California, San Francisco, CA, USA
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15
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De J, Wand APF, Smerdely PI, Hunt GE. Validating the 4A's test in screening for delirium in a culturally diverse geriatric inpatient population. Int J Geriatr Psychiatry 2017; 32:1322-1329. [PMID: 27766672 DOI: 10.1002/gps.4615] [Citation(s) in RCA: 53] [Impact Index Per Article: 7.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/06/2016] [Revised: 09/30/2016] [Accepted: 10/05/2016] [Indexed: 01/12/2023]
Abstract
OBJECTIVE To measure the diagnostic accuracy of the 4A's test in screening for delirium in geriatric inpatients from culturally diverse backgrounds. METHODS A prospective study was conducted with patients admitted to the geriatric and orthogeriatric services of a tertiary teaching hospital. Consenting participants aged 65 years and over were screened for delirium with the 4AT by nursing staff within 72 h of admission. The diagnosis of delirium was made separately by expert assessors, responsible for the participant's clinical care, blinded to the 4AT score, within 30 min of the 4AT assessment using the DSM 5 criteria and the Confusion Assessment Method. Interpreters were used for non-English speaking patients. The Informant Questionnaire for Cognitive Decline in the Elderly was completed by a carer/relative to assess for probable dementia. RESULTS A total of 257 participants (mean age 85) were recruited over five months. Delirium was diagnosed in 159 (62%) by the expert assessors and 158 (62%) by the 4AT assessment. A total of 205 participants (80% of total population) had probable dementia. The sensitivity and specificity of the 4AT were 87% and 80%, respectively, in detecting delirium overall, 86% and 71% in people with probable dementia and 91% and 71% for non-English speaking participants. The area under the receiver operating characteristic curve for delirium in the whole population was 0.92, 0.89 in the probable dementia subgroup and 0.90 in non-English speaking participants. CONCLUSIONS The 4AT is a sensitive and specific screening tool for delirium in geriatric inpatients, including those with probable dementia or who are non-English speaking. Copyright © 2016 John Wiley & Sons, Ltd.
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Affiliation(s)
- Jayita De
- Department of Aged Care, St George Hospital, South Eastern Sydney Local Health District, Australia.,Faculty of Medicine, University of New South Wales, Australia
| | - Anne P F Wand
- Faculty of Medicine, University of New South Wales, Australia.,Older Persons Mental Health Service, St George Hospital, South Eastern Sydney Local Health District, Australia
| | - Peter I Smerdely
- Department of Aged Care, St George Hospital, South Eastern Sydney Local Health District, Australia.,Faculty of Medicine, University of New South Wales, Australia
| | - Glenn E Hunt
- Discipline of Psychiatry, Sydney Medical School, University of Sydney, NSW, Australia.,Concord Centre for Mental Health, Concord Repatriation and General Hospital, Sydney Local Health District, Australia
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16
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New horizons in geriatric medicine education and training: The need for pan-European education and training standards. Eur Geriatr Med 2017. [DOI: 10.1016/j.eurger.2017.07.022] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
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17
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Cerveira CCT, Pupo CC, Dos Santos SDS, Santos JEM. Delirium in the elderly: A systematic review of pharmacological and non-pharmacological treatments. Dement Neuropsychol 2017; 11:270-275. [PMID: 29213524 PMCID: PMC5674671 DOI: 10.1590/1980-57642016dn11-030009] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/30/2023] Open
Abstract
Delirium is a common disorder associated with poor prognosis, especially in the elderly. The impact of different treatment approaches for delirium on morbimortality and long-term welfare is not completely understood. OBJECTIVE To determine the efficacy of pharmacological and non-pharmacological treatments in elderly patients with delirium. METHODS This systematic review compared pharmacological and non-pharmacological treatments in patients over 60 years old with delirium. Databases used were: MEDLINE (PubMed), EMBASE, Cochrane CENTRAL and LILACS from inception to January 6th, 2016. RESULTS A total of ten articles were selected. The six non-pharmacological intervention studies showed no impact on duration of delirium, mortality or institutionalization, but a decrease in severity of delirium and improvement in medium-term cognitive function were observed. The most commonly used interventions were temporal-spatial orientation, orientation to self and others, early mobilization and sleep hygiene. The four studies with pharmacological interventions found that rivastigmine reduced the duration of delirium, improved cognitive function and reduced caregiver burden; olanzapine and haloperidol decreased the severity of delirium; droperidol reduced length of hospitalization and improved delirium remission rate. CONCLUSION Although the pharmacological approach has been used in the treatment of delirium among elderly, there have been few studies assessing its efficacy, involving a small number of patients. However, the improvements in delirium duration and severity suggest these drugs are effective in treating the condition. Once delirium has developed, non-pharmacological treatment seems less effective in controlling symptoms, and there is a lack of studies describing different non-pharmacological interventions.
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Affiliation(s)
| | - Cláudia Cristina Pupo
- MD, Departamento de Medicina, Centro de Ciências Biológicas e da Saúde, Universidade Federal de São Carlos, SP, Brazil
| | - Sigrid De Sousa Dos Santos
- MD, PhD, Departamento de Medicina, Centro de Ciências Biológicas e da Saúde, Universidade Federal de São Carlos, SP, Brazil
| | - José Eduardo Mourão Santos
- MD, PhD, Departamento de Medicina, Centro de Ciências Biológicas e da Saúde, Universidade Federal de São Carlos, SP, Brazil
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18
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St-Hilaire A, Hudon C, Préville M, Potvin O. Utilization of healthcare services among elderly with cognitive impairment no dementia and influence of depression and anxiety: a longitudinal study. Aging Ment Health 2017; 21:810-822. [PMID: 26998576 DOI: 10.1080/13607863.2016.1161006] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/22/2022]
Abstract
OBJECTIVES Little objective and nationally representative data are available concerning the influence of cognitive impairment no dementia (CIND) on utilization of healthcare services. The main objective was to compare the use of healthcare services over three years, between elders with current or incident CIND and those without CIND. A second objective was to evaluate the effect of depression and anxiety. METHODS Cross-sectional and longitudinal data from a population-based survey of 2265 older adults living in Quebec (Canada) were used. CIND was identified using normative data for the Mini-Mental State Examination and was linked with medical records from public health insurance plan. Multinomial logistic regressions adjusted for relevant socio-demographic, social network and health-related confounders were conducted for each service. Interaction between CIND and depression/anxiety was also examined. MAIN RESULTS Current CIND was a predictor of longer anxiolytic/sedative/hypnotic medication use. Incident CIND led to longer hospital stay. Depression raised the likelihood of frequenting geriatricians, psychiatrists or neurologists and emergency department, but lessened the likelihood of visiting general practitioners. The addition of the psychiatric conditions to the incident CIND did not increase the likelihood of consuming antidepressants, while the incident CIND cases without psychiatric conditions increased this likelihood. DISCUSSION Compared to older adults without CIND, older adults with CIND have a distinct utilization of healthcare services. Multiple evaluations over many years may help to better understand the utilization of healthcare services in individuals with CIND. In the meantime, evaluations of these conditions at key moments could allow a more efficient use of health resources.
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Affiliation(s)
| | - Carol Hudon
- a École de psychologie , Université Laval , Québec , QC , Canada.,b Centre de recherche de l'Institut universitaire en santé mentale de Québec , Québec , QC , Canada
| | - Michel Préville
- c Département des sciences de la santé communautaire , Université de Sherbrooke , Sherbrooke , QC , Canada.,d Centre de recherche Hôpital Charles LeMoyne , Longueuil , QC , Canada
| | - Olivier Potvin
- b Centre de recherche de l'Institut universitaire en santé mentale de Québec , Québec , QC , Canada
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Delirium superimposed on dementia: phenomenological differences between patients with and without behavioral and psychological symptoms of dementia in a specialized delirium unit. Int Psychogeriatr 2017; 29:485-495. [PMID: 27917740 DOI: 10.1017/s1041610216001836] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
BACKGROUND Overlap between neuropsychiatric symptoms of dementia and delirium complicates diagnosis of delirium superimposed on dementia (DSD). This study sought to examine differences in delirium presentation and outcomes between DSD patients with and without pre-existing behavioral and psychological symptoms of dementia (BPSD). METHODS This was a prospective cohort study of older adults with DSD admitted to a specialized delirium unit (December 2010-August 2012). We collected data on demographics, comorbidities, illness severity, delirium precipitants, and cognitive and functional scores. Delirium severity was assessed using Delirium Rating Scale Revised-98 (DRS-R-98) and Cognitive Assessment Method severity score (CAM-sev). Patients were categorized as DSD-BPSD+ and DSD-BPSD- based on elicited behavioral and psychological disturbances. RESULTS We recruited 174 patients with DSD (84.4 +/-7.4 years) with 37 (21.3%) having BPSD. At presentation, delirium severity and symptom frequency on DRS-R98 were similar, but DSD-BPSD+ more often required only a single precipitant (40.5% vs. 21.9%, p = 0.07), and had significantly longer delirium duration (median days: 7 vs. 5, p < 0.01). At delirium resolution, DSD-BPSD+ exhibited significant improvement in sleep-wake disturbances (89.2% vs. 54.1%, p < 0.01), affect lability (81.1% vs. 56.8%, p = 0.05), and motor agitation (73% vs. 40.5%, p < 0.01), while all non-cognitive symptoms except motor retardation were improved in DSD-BPSD-. Pharmacological restraint was more prevalent (62.2% vs. 40.1%, p = 0.03), and at higher doses (chlorpromazine equivalents 0.95 +/-1.8 vs. 0.40 +/-1.2, p < 0.01) in DSD-BPSD+. CONCLUSIONS BPSD may increase vulnerability of dementia patients to delirium, with subsequent slower delirium recovery. Aggravation of sleep disturbance, labile affect, and motor agitation should raise suspicion for delirium among these patients.
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Bail K, Grealish L. ‘Failure to Maintain’: A theoretical proposition for a new quality indicator of nurse care rationing for complex older people in hospital. Int J Nurs Stud 2016; 63:146-161. [DOI: 10.1016/j.ijnurstu.2016.08.001] [Citation(s) in RCA: 94] [Impact Index Per Article: 11.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/16/2015] [Revised: 07/27/2016] [Accepted: 08/04/2016] [Indexed: 01/20/2023]
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21
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Angel C, Brooks K, Fourie J. Standardizing Management of Adults with Delirium Hospitalized on Medical-Surgical Units. Perm J 2016; 20:16-002. [PMID: 27644045 DOI: 10.7812/tpp/16-002] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/19/2023]
Abstract
CONTEXT Delirium is common among inpatients aged 65 years and older and is associated with multiple adverse consequences, including increased length of stay (LOS). However, delirium is frequently unrecognized and poorly understood. At one hospital, baseline management of delirium on medical-surgical units varied greatly, and psychiatric consultations focused exclusively on crisis management. OBJECTIVE To implement a multidisciplinary program for rapid identification and proactive management of patients with delirium on medical-surgical units. DESIGN A pilot from September 2010 to July 2012 included 920 unique patients, of whom 470 were seen by the delirium management team. A delirium management team included a redesigned role for consulting psychiatrists and a new clinical nurse specialist role; the team provided assistance with diagnosis and recommendations for nonpharmacologic and pharmacologic management of delirium. Multidisciplinary education focused on delirium identification and management and nurses' use of appropriate assessment tools. Electronic health record functions supported accurate problem list coding, referrals to the team, and standardized documentation. MAIN OUTCOME MEASURE Length of stay. RESULTS During the study period, average LOS in the target population decreased from 8.5 days to 6.5 days (p = 0.001); average LOS for the Medical Center remained stable. Compared with patients whose delirium was diagnosed during the baseline period, patients who received a delirium diagnosis during the pilot period had a higher illness burden and were likelier to have a history of delirium and diagnosed dementia. CONCLUSION Program implementation was associated with reduced LOS among older inpatients with delirium. The delirium team is an effective model that can be quickly implemented with few additional resources.
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Affiliation(s)
- Clay Angel
- Chief of Service for Skilled Nursing Facilities at the San Rafael Medical Center in CA.
| | - Kristen Brooks
- Consultant Liaison in Psychiatry for the San Rafael Medical Center in CA.
| | - Julie Fourie
- Clinical Consulting Manager at the San Rafael Medical Center in CA.
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von Renteln-Kruse W, Neumann L, Klugmann B, Liebetrau A, Golgert S, Dapp U, Frilling B. Geriatric patients with cognitive impairment. DEUTSCHES ARZTEBLATT INTERNATIONAL 2016; 112:103-12. [PMID: 25780869 DOI: 10.3238/arztebl.2015.0103] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/14/2014] [Revised: 10/21/2014] [Accepted: 10/21/2014] [Indexed: 12/15/2022]
Abstract
BACKGROUND Hospitals are now faced with increasing numbers of cognitively impaired patients aged 80 and older who are at increased risk of treatment complications. This study concerns the outcomes when such patients are treated in a specialized ward for cognitive geriatric medicine. METHODS Observation of a cohort of 2084 patients from 2009 to 2014, supplemented by a sample of 380 patients from the hospital cohort of the Longitudinal Urban Cohort Ageing Study (LUCAS) for the years 2010 and 2011. RESULTS Geriatric inpatients with cognitive impairment tend to be multimorbid. Half of the patients studied (1031 of 2084 patients) were admitted to the hospital on an emergency basis. Complications arising on the ward that necessitated transfer elsewhere arose in 2.6% (51 of 2084 patients). Moreover, analysis of the sample of 380 patients from the LUCAS cohort revealed that the treatments they underwent during hospitalization were associated with an improvement of their functional state: their mean overall score on the Barthel index rose from 39.8 ± 24.3 (median, 35) on admission to 52.7 ± 27.0 (median, 55) on discharge. The percentage of patients being treated with 5 or more drugs fell from 98.2% (373/380) on admission to 79.3% (314/362) on discharge. The percentage receiving potentially inappropriate medications (PIM), as defined by the PRISCUS list, fell from 45% to 13.3%, while the percentage of drug orders and prescriptions involving PIM fell from 7.8 % (327/4181) to 2.0% (53/2600). 70% of the patients were discharged to the same living situation where they had been before admission. CONCLUSION In this study, structured geriatric treatment in a cohort of older acutely ill patients with cognitive impairment was associated with improvement of functions that are relevant to everyday life, as well as with a reduction of polypharmacy. Controlled studies are needed to confirm the observed benefit.
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Affiliation(s)
- Wolfgang von Renteln-Kruse
- Albertinen-Haus, Geriatrics Centre, Scientific Department at the University of Hamburg, Hamburg, Germany, Albertinen-Haus, Geriatrics Centre, Scientific Department at the University of Hamburg, Research Department, Hamburg Germany, Albertinen-Hospital, Department of Medical Controlling, Hamburg, Germany
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De J, Wand APF. Delirium Screening: A Systematic Review of Delirium Screening Tools in Hospitalized Patients. THE GERONTOLOGIST 2015; 55:1079-99. [DOI: 10.1093/geront/gnv100] [Citation(s) in RCA: 163] [Impact Index Per Article: 18.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/31/2015] [Accepted: 06/04/2015] [Indexed: 11/14/2022] Open
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Identifying phenomenological differences and recovery of cognitive and non-cognitive symptomatology among delirium superimposed upon dementia patients (DsD) versus those without dementia (DaD) in an acute geriatric care setting. Int Psychogeriatr 2015; 27:1695-705. [PMID: 26055222 DOI: 10.1017/s1041610215000770] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/07/2022]
Abstract
BACKGROUND Phenomenological differences between delirium superimposed on dementia (DsD) versus delirium in the absence of dementia (DaD) remain poorly understood. We aimed to identify phenomenological differences in delirium symptoms (cognitive and non-cognitive) and compare delirium recovery trajectories between DsD and DaD. METHODS We conducted a prospective observational study on individuals admitted to the Geriatric Monitoring Unit (GMU), a five-bed unit specializing in managing older adults with delirium, between December 2010 and August 2012 (n = 234; mean age 84.1 ± 7.4). We collected data on demographics, comorbidities, severity of illness, cognitive and functional scores, and number of precipitants. Cognitive status was assessed using locally validated Chinese Mini-Mental State Examination (CMMSE) and delirium severity assessed using Delirium Rating Scale-Revised-98 (DRS-R98). Delirium disease trajectory was plotted over five days. RESULTS DsD patients had a longer duration of delirium with slower recovery in terms of cognition and delirium severity scores compared with DaD patients (0.33 (0.0-1.00) vs. 1.0 (0.36-2.00) increase in CMMSE per day, p < 0.001, and 1.49 ± 1.62 vs. 2.63 ± 2.28 decrease in DRS-R98 severity per day, p < 0.001). When cognitive and non-cognitive sub-scores of DRS-R98 were examined separately, we observed steeper recovery in both sub-scores in DaD patients. These findings remained significant after adjusting for significant baseline differences. CONCLUSIONS Our findings of slower cognitive symptom recovery in DsD patients suggest cognitive reserve play a role in delirium syndrome development and recovery. This merits further studies to potentially aid in appropriate discharge planning and to identify potential pharmacological and non-pharmacological cognitive interventions for hospitalized older persons with delirium.
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Abstract
Changing global demography is resulting in older people presenting to emergency departments (EDs) in greater numbers than ever before. They present with greater urgency and are more likely to be admitted to hospital or re-attend and utilize greater resources. They experience longer waits for care and are less likely to be satisfied with their experiences. Not only that, but older people suffer poorer health outcomes after ED attendance, with higher mortality rates and greater dependence in activities of daily living or rates of admission to nursing homes. Older people's assessment and management in the ED can be complex, time consuming, and require specialist skills. The interplay of multiple comorbidities and functional decline result in the complex state of frailty that can predispose to poor health outcomes and greater care needs. Older people with frailty may present to services in an atypical fashion requiring detailed, multidimensional, and increasingly multidisciplinary care to provide the correct diagnosis and management as well as appropriate placement for ongoing care or admission avoidance. Specific challenges such as delirium, functional decline, or carer strain need to be screened for and managed appropriately. Identifying patients with specific frailty syndromes can be critical to identifying those at highest risk of poor outcomes and most likely to benefit from further specialist interventions. Models of care are evolving that aim to deliver multidimensional assessment and management by multidisciplinary specialist care teams (comprehensive geriatric assessment). Increasingly, these models are demonstrating improved outcomes, including admission avoidance or reduced death and dependence. Delivering this in the ED is an evolving area of practice that adapts the principles of geriatric medicine for the urgent-care environment.
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Affiliation(s)
- Graham Ellis
- Medicine for the Elderly, Monklands Hospital, Airdrie, Scotland, UK
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